The Psychiatric Examination in the Walk-In Clinic Hypothesis Generation Aaron
and
Hypothesis Testing
Lazare, MD
\s=b\ Rapid assessment for decision making is a major goal of the initial psychiatric interview in walk-in clinics, emergency psy¬ chiatric services, and the ambulatory services of community mental health centers. To accomplish this task, the clinician must learn to elicit specific data to confirm or refute clinical hy¬ potheses rather than gather a complete history. This report, in formulating a hypothesis generating and testing approach for the initial psychiatric examination, proposes 16 hy¬ potheses that organize the clinical data necessary for most deci¬ sions. This approach is intended to help the clinician make ef¬ ficient use of limited time, guard him from coming to premature closure in the collection of data, and provide a stimulus for the exploration of relevant but neglected clinical questions. (Arch Gen Psychiatry 33:96-102, 1976)
are expected to make more rapid decisions in order to pro¬ vide competent care for more patients per unit time. What clinicians have done in developing their skills is to change strategies for diagnosis and case formulation from the collection and assimilation of large amounts of data to the generation and testing of various hypotheses. Using this new approach, they consider a limited number of pos¬ sibilities based on critical observations usually made early in the interview. They then proceed to elicit specific data to confirm or refute the hypotheses under consideration rather than "get a complete history." For the expert clini¬ cian, the probability that the correct diagnosis or formula¬ tion will be found among the early hypotheses is quite
high.13
learn the techniques of inter¬ and evaluation by collecting and recording numbers of observations from patients whom they see over extended periods of time. The data are then orga¬ nized in some fashion, such as chief complaint, present ill¬ ness, family history, developmental history, sexual his¬ tory, occupational history, medical history, and mental status examination. Finally, the clinician sorts out symp¬ toms, themes, and processes in order to establish a diag¬ nosis and formulation. The opportunity for this kind of intensive study is provided by inpatient units where pa¬ tients stay for a long enough period of time and by psy¬ chotherapy clinics where patients are stable enough to re¬ turn for several visits. As clinicians gain experience over months and years, they begin to take shortcuts. Sensing where the "pay dirt" is, they ignore extraneous information while focusing their energies on the elicitation of data that is apt to make a difference in clinical management. This improve¬ ment in efficiency becomes necessary because they soon
Cllargeiniviewing cians initially
Accepted for publication Feb 11, 1975. From the Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston. Reprint requests to the Department of Psychiatry, Massachusetts General Hospital, Fruit St, Boston, MA 02114 (Dr Lazare).
The hypothesis generation and testing approach, prac¬ ticed intuitively by most clinicians, has been alluded to but not systematically discussed in the literature on the general psychiatric examination.417 This process has been described in depth by Weisman18 and Erikson19 in their discussions of facts and inferences in the psychodynamic formulation. Elstein et al20 have shown that experienced internists examine medical patients by the generation and testing of hypotheses, thus confirming in a research setting what has long been noted in clinical medicine. A similar approach for the consultation in general practice has been recommended by the Royal College of General Practitioners.21 This group suggests that the hypotheses include not only diagnoses but an extended range of social and psychological components of the diagnostic process. In walk-in clinics, emergency psychiatric services, health maintenance organizations, and the ambulatory services of community mental health centers where a pri¬ mary goal is rapid assessment and decision making, it is obviously difficult to collect and assimilate large amounts of data. Yet clinicians must decide within a limited amount of time whether or not a patient is suicidal, is in need of hospitalization, needs psychotropic agents, can be helped in a few sessions, needs an extended diagnostic evaluation, or may leave with no additional care. The dan¬ ger is always present that incomplete data will result in incorrect decisions. This report will attempt to formulate an hypothesis
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for the initial psychiat¬ ric examination in walk-in clinics and related settings. Sixteen hypotheses that my colleagues and I have found useful in organizing clinical data will be described. I will attempt to show that this approach (1) helps the clinician make efficient use of limited time in attempting to be comprehensive, (2) guards the clinician from coming to premature closure in the collection of data, and (3) pro¬ vides a stimulus for the exploration of relevant but ne¬ glected clinical questions. In considering the interview as hypothesis generation and testing, the focus is on the collection and organization of data. Three important dimensions of the psychiatric ex¬ amination that will not be discussed are (1) the patient's goals and requests2224; (2) the therapeutic aspects of the clinician patient interaction, including the negotiation of goals and requests, which hopefully occur even before a specific treatment plan is formulated; and (3) the tech¬ niques necessary to elicit relevant data.
generating and testing approach
A MULTIDIMENSIONAL APPROACH
The hypotheses to be considered and the clinical meth¬ ods needed to test them depend on a theoretical frame¬ work. I shall, therefore, make explicit an approach that we have found useful. This approach and its clinical implica¬ tions are discussed more fully elsewhere.25 Although "human beings are simultaneously biological organisms, psychological selves, behaving animals, and members of social systems,"25 we lack a theory of human behavior that satisfactorily integrates these four dimen¬ sions. Attempts by psychoanalysts, behaviorists, or gen¬ eral system theorists to describe a comprehensive theory of human behavior are either too cumbersome or not ade¬ quately inclusive. Clinicians, in the absence of such a com¬ prehensive theory, implicitly use one or a combination of models that include the psychologic, social, biologic, and behavioral. These models may be thought of as different lenses through which one can observe a single object. Each lens has its own value and each has its own limitations. The choice of conceptual approach in clinical practice has serious implications, since it may determine the method by which one collects data, the data that are con¬ sidered relevant, and the treatment that is most appropri¬ ate. For example, a clinician using a psychologic approach to examine a depressed patient may elicit a history of un¬ resolved grief or explore the psychologic meaning of the precipitating event in order to understand the issues that have led to the depression. A clinician using a social ap¬ proach to examine the same patient may determine how the disruption of the social matrix led to the patient's be¬ coming depressed. Hopefully, there will be some way of reestablishing some social equilibrium. Using a biologic approach, the clinician will inquire into the signs and symptoms of a unipolar or bipolar depression, previous episodes of depression, and family history of depressive illness in the hopes of diagnosing a syndrome for which there is a somatic treatment. Using a behavioral ap¬ proach, the clinician will elicit the undesired behaviors to¬ gether with their antecedent and reinforcing conditions in the hopes of positively reinforcing normal behavior or ex¬ tinguishing depressive behavior.
In clinical practice, the use of one or a combination of the four conceptual models is implicitly determined by many variables. These include the ideology of the thera¬ pist, the diagnosis, the responsiveness of the symptoms to somatic treatment, the treatment resources, the social class of the patient, and other personal attributes such as verbal intelligence, psychological mindedness, young adult age, psychological strengths, likeability, and attractive¬ ness.26
Clinicians are sometimes unaware of how these vari¬ ables influence their clinical judgment. When this hap¬ pens, they run the risk of dealing with diffuse and incom¬ plete data, an approach that may be inappropriately termed "eclectic."27 In the examination of the walk-in patient for whom various conceptual frameworks are often relevant, the pit¬ falls described above can be minimized by simultaneously formulating the problem from psychologic, social, biologic, and behavioral perspectives. This means that hypotheses from all four theoretical frameworks are considered. In this way, the chances of making the appropriate clinical mix yielding the optimal therapeutic gain will be en¬ hanced.25·2830 HYPOTHESES: HYPOTHESIZED PARTIAL FORMULATIONS
A clinician brings to the interview partial formulations based on his previous experience. A formulation is defined here as a concept that organizes, explains, or makes clini¬ cal sense out of large amounts of data and influences the treatment decision. These concepts include clinical syn¬ dromes such as schizophrenia; personality styles, such as the hysterical personality; social conditions, such as social isolation; and even symptoms such as suicidal behavior. These concepts may be "apples and oranges," but they do represent clusters of information that clinicians find use¬ ful in understanding patients. In Weisman's terms, "This is the nature of communication between people—to oper¬ ate on many levels at once with different words, different objects, and different meanings."18 These concepts are partial formulations because any one alone is insufficient to provide adequate understanding of any given patient. In the process of bringing these partial formulations to the interview for consideration, they become hypotheses to be tested. The clinician by thinking in terms of hypotheses keeps himself from being bombarded or overloaded with large amounts of unstructured data. Each new observation can now be considered in terms of its relevance to a limited number of hypotheses under consideration instead of being one out of thousands of possible facts.20 Two problems immediately arise in applying this ap¬ proach to the psychiatric examination. The first is that in considering a few hypotheses usually generated early in the interview, the clinician may come to premature clo¬ sure, thereby ignoring more relevant hypotheses. The sec¬ ond is that, given the rich and varied data of clinical psy¬ chiatry, there must be thousands of possible hypotheses or ways of organizing data. A solution to both problems would be the development of a manageable list of hypoth¬ esized partial formulations based on current psychiatric knowledge, which would organize most of the observations
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might relate to decision making. The entire range of hypotheses could then be considered, at least briefly, dur¬ ing each interview. The composition of such a list might vary with the clinical setting and would undoubtedly change with advances in the field. This report will propose 16 hypotheses that my col¬ leagues and I have found useful in evaluating and treat¬ ing patients in our walk-in clinic. They are organized un¬ der four major headings: psychologic, social, biologic, and behavioral (according to the conceptual approach whose theory and methods generate, confirm, or refute the hy¬ pothesis). These hypothesized partial formulations are in¬ tended to become neither decision trees nor a complete list of diagnoses. Rather, they are intended to assist in the clinical understanding of patients so that decisions can more effectively be made, and to provide a basis for impor¬ tant theoretical discussions as to which hypotheses belong that
in such a list. There is some overlap between various partial formula¬ tions since they may explain similar observations from different perspectives. For instance, calling a patient schiz¬ oid (psychologic) or socially isolated (social) may be de¬ scribing some of the same phenomena from different per¬
spectives.
For any given patient, several partial formulations will be necessary to approach "complete understanding"; for example, knowing that a patient is suffering from unre¬ solved grief tells us a great deal. Add to this partial for¬ mulation the knowledge of an obsessional personality style, the ego's incapacity to bear painful affective states, relative social isolation, and a behavioral system that pun¬ ishes grieving behavior. These additional partial formula¬ tions provide the clinician with considerably more power to understand and treat the patient.
Psychologic Hypotheses Knowledge of the patient's personality style explains in part why he has come for treatment. Knowledge of the personality style may be important in understanding the patient's psychological vulnerabilities and, therefore, the meaning of the stress or precipitating event. It may also predict the defensive posture that the patient will employ to keep the clinician from getting to the important psy¬ chological issues surrounding the current problem.3134 Armed with this knowledge, the clinician can avoid the patient's diversionary tactics and more effectively get to the heart of the matter. This hypothesis, with its potential for making sense out of large amounts of data, can often be inferred from a relatively small number of observa¬ tions obtained early in the interview. Knowledge of the precipitating event and its dynamic meaning explains in part why the patient has come for treatment. It is essential to learn the stress or precipi¬ tating event (when present) that precedes the onset of
symptoms. At least
important
is the
psychological meaning of this event. Does the event mean to the patient that he is now hopeless, weak, powerless, out-of-control, as
failure, unreal, or unloved? Does attacked, penetrated, vio¬ lated, damaged, overwhelmed, smothered, ridiculed, or destructive, bad, it
mean
a
to him that he is
cheated?3538 Is the precipitating event evidence of a recur-
rent neurotic theme? Knowing the psychological meaning of the event improves rapport because the patient now be¬
lieves the clinician really appreciates what is happening. At least as important, the clinician may know with consid¬ erable specificity the psychological work that needs to be done. The patient's problem can be understood in part as a manifestation of unresolved grief. This hypothesis is a variation on the previous one when it is determined, for instance, that the symptoms followed a loss that the pa¬ tient inadequately mourned. The grief hypothesis, how¬ ever, is worth considering separately for several reasons: (1) the symptom picture may not follow a discrete stress but may occur after an anniversary of a loss, a holiday, or a minor event symbolizing the loss; (2) the symptom pic¬ ture of unresolved grief represents a relatively clear-cut clinical syndrome39; (3) specific methods must be employed to elicit the necessary observations to confirm or refute the hypothesis; and (4) I have found a relatively high inci¬ dence (10% to 15%) of patients coming to a walk-in clinic for whom unresolved grief is an important issue. The patient's problem can be understood in part as a de¬ velopmental crisis. When it is difficult to understand the patient's presentation as a reaction to a discrete event or as a manifestation of unresolved grief, the problem may be better understood as part of a developmental crisis. Using this approach, the clinician considers what series of issues the patient at his stage of development is apt to be suffering from. For instance, a 50-year-old woman may well be struggling simultaneously with menopause, chil¬ dren leaving home, strains in the marital relationship, and the death of a parent. With the developmental crisis hy¬ pothesis in mind, the clinician can elicit specific historical data that may clarify the clinical problem.40"41 The patient's problem can be understood in part in terms of ego functioning and related psychodynamic is¬ sues. There are many subconcepts or ways of organizing the data of ego assessment and related psychodynamic is¬ sues. These include recurrent neurotic themes, meaning of neurotic symptoms, predominant defense mechanisms, overall defensive success, reality testing, sense of reality, judgment, thought processes, tolerance to stress, capacity to bear affects, impulse control, patterns of regression, au¬ tonomous functioning, synthetic functioning, conflict-free areas, libidinal fixation, object relations, sexual identi¬ fication, superego severity and integration, and psycho¬ logical mindedness. A clinician using a psychodynamic ap¬ proach usually chooses a few of these overlapping concepts to help explain the patient's problem and plan treatment. Confirmation of the ego-assessment hypothesis often re¬ quires data from many sources including developmental history, dreams, associations, and transference reac¬ tions.4244 Social
Hypotheses Cultural factors explain in part the patient's problem and his reasons for seeking treatment. It is important to consider to what degree cultural factors influence percep¬ tions, beliefs, values, behavioral norms, and expectations that give clues as to the choice, expression, and serious¬ ness
of
symptomatology. Cultural
factors also influence
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the choice of and attitudes toward treatment and even the basic communicative processes between clinician and pa¬ tient.4550 The patient's problem can be understood in part in terms of a change in the social space. The social space (so¬ cial network) consists of all relevant people (and animals) in the patient's life—at home, with friends, at school, and on the job. The clinical presentation can often be under¬ stood in terms of a disruption or impending disruption of the social space that had previously supported the patient. To explore this hypothesis, the patient may be asked to list and briefly describe all the important people in his life. By listening for the order in which people are listed, for the associated affective responses, and for the omissions of important people, the clinical picture often falls into place. The recovery process will depend in large part on the availability of important relationships.5154 Social isolation explains in part the patient's problem. For many patients who come to a walk-in clinic, the pau¬ city of their social contacts may explain what they ask for and what they need from the clinician.55 They often make modest requests, perhaps a prescription refill or someone to speak with for a few minutes. The social isolation may be characterological in origin, or it may be the result of so¬ cial transition such as a recent move. Shuvall has shown that social transition is a cause for presentation to medi¬ cal clinics in Israel.56 This hypothesis is tested only by spe¬ cific inquiry into the patient's social space. The patient's problem can be understood in part as a so¬ cial communication. The symptom or even the clinic visit can be understood as an attempt to influence or to commu¬ nicate something to some person, social group, or institu¬ tion. This hypothesis, like the one above, can be deter¬ mined by reviewing the persons or groups in the patient's life space. The questions are as follows: Who wants what from whom? and Who is doing what to whom? Sometimes the communication can be discerned by watching the pa¬ tient with a relative in the waiting room or at a family conference. The communication may or may not be con¬ scious.5762 The patient's problem can be understood in part in terms of its social impact, including suicide or violence. The importance of this hypothesis is self-evident. Once it is confirmed that the patient is suicidal, violent, or in dan¬ ger of harming others, the clinician then calls forth a new body of knowledge to explore seriousness, cause, and
treatability.
Biologic Hypotheses The
patient's problem can be understood in part as an affective disorder (unipolar or bipolar).6365 This hypothesis should be considered because of its rela¬ tively high incidence, its treatability, the dangers inher¬ ent in the clinical course when rigorous treatment is de¬ layed, and the important differential diagnosis of syndromes that appear to be affective disorders. Although psychologic, social, and behavioral considerations are es¬ sential in the understanding and management of these patients, affective disorder is listed as biologic since the hypothesis is usually established by the method of the biologic approach—observations of signs and symptoms
through time.
In
addition, there
are
treatments for these disorders.
important somatic
The patient is suffering in part from schizophrenia."46'' This hypothesis, like the previous one, should be consid¬ ered because of its frequency, its treatability, the dangers inherent in its clinical course when treatment is delayed, and the differential diagnoses of syndromes that assume this manner. Although the hypothesis is usually estab¬ lished by the biologic method, psychodynamic, social, and behavioral considerations are essential in the under¬ standing and management of these patients. The patient's problem can be understood in part as an organic disease. It is useful to divide this hypothesis into conditions that are with and without impairments of the sensorium. The latter group is most likely to be over¬ looked. The clinician should consider a differential diag¬ nosis that includes organic illness even in the presence of a clean sensorium when he observes psychotic thinking, mania, depression, anxiety, impotence, eneuresis, syncope, amnesia, pain, and various sensory and motor distur¬ bances. The patient is suffering in part from alcohol or drug abuse. This hypothesis deserves separate consideration since (1) its occurrence is common; (2) patients are reluctant to acknowledge their abuse of alcohol and drugs; (3) health professionals because of hostile feelings toward many of these patients may overlook the problem; and (4) the ab¬ use of these agents, aside from their complex causes, sets in motion a series of medical, social, and psychological problems that may require special therapeutic techniques. The patient's problem can be understood in part in terms of symptoms responsive to psychotropic agents. The separate consideration of psychotropic agents assures that an important treatment possibility is not overlooked. Behavioral
Hypotheses
The patient's problem can be understood in part in be¬ havioral terms. For each patient, the clinician should con¬ sider whether or not an understanding of the undesired behaviors together with their antecedent and reinforcing events will lead to a plan of treatment. In addition, it should be considered whether or not there already exists specific treatment programs for these behaviors.68·69 THE DYNAMICS OF HYPOTHESIS GENERATION AND TESTING
Hypothesis generation and testing can be thought of as three-step mental process repeated many times through¬ out the interview by which the clinician (1) collects data (makes observations); (2) generates, confirms, and refutes hypotheses on the basis of the data collected; and (3) em¬ ploys clinical methods or strategies to elicit additional data that will generate new hypotheses and confirm or re¬ a
fute old
ones.
Data Collection
The observations
data that lead to hypothesis gener¬ and refutation may come (1) from ation, confirmation, outside the patient (previous records, clinic face sheet, and information from the family); (2) from the patient's bio¬ graphical reconstructions; (3) from the mental status exor
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amination (behavior observations made during the inter¬ view); (4) from the physical examination and laboratory data; (5) from psychodynamic material including dreams, fantasies, memories, associations, recurrent themes, transference, and countertransference reactions; and (6)
from social interactions in ences,
homes,
or
waiting neighborhoods.
rooms,
family confer¬
What there is to observe is a result of the clinician's methods, the patient's disorder, and other dimensions of the clinical situation such as the size of the room, the posi¬ tion of the chairs, the duration of the wait, and the time of day. The clinician's ability to perceive the observations de¬ pends on what he thinks is important and on his ability to see what is in front of him.
Hypothesis Generation and Testing
Although the clinician can briefly consider all of the hy¬ potheses on the list, it is usually possible to explore only a few in depth. The selection of these few is best deter¬ mined by several criteria. 1. One considers hypotheses that are most probable on the basis of available data. For example, fastidious dress may lead to consideration of an obsessional style; recur¬ rent presentations on the same date may lead to consid¬ eration of unresolved grief. 2. One considers those hypotheses that are most serious, even though they may not be highly probable. These in¬ clude suicide, organic brain disease, and schizophrenia. 3. One gives special consideration to those hypotheses that have a high probability of being reversed with treat¬ ment, such as primary affective disorders, unresolved grief, and acute brain syndromes. 4. One considers those hypotheses for which there are treatment resources. For example, if psychotherapy time is available, one explores various ego functions to deter¬ mine whether or not the patient is a candidate for this treatment.
5. One considers those hypotheses that the patient be¬ lieves are relevant. The patient is often right and, if he is wrong, it will be important that he knew his concerns have been taken seriously. Which hypotheses the clinician tests depend not only on the priorities listed above but on his awareness of the range of hypotheses to be tested and on his ability to re¬ late specific data to the formation, refutation, and confir¬ mation of hypotheses. For instance, the clinician must know that delusions may be part of schizophrenia, affec¬ tive disorders, or organic brain disease, if this symptom is to alert him to test these hypotheses.
Strategies: Methods After the clinician generates several hypotheses on the basis of the available observations, he develops a strategy to test these hypotheses. To do this, the clinician must know what additional data are required to confirm or re¬ fute any given hypothesis. He then sets out to collect these data by various methods, such as direct questioning, sitting in silence, employing the associative anamnestic technique, encouraging free associations, speaking to the family, testing the patient's memory, paying attention to his own subjective responses, stressing the patient, using
sodium amytal, or evaluating the response of a trial medi¬ cation. Many of these methods can be traced to the four basic conceptual frameworks previously described. The ef¬ fectiveness of the method will depend on choosing the proper one for the particular hypothesis, the skill of the clinician, and the responsiveness of the patient. Particular methods may have to be withheld if they are antitherapeutic. For example, the stress of extended silence may yield useful data but impair the treatment relationship. Conduct of the Interview
In conducting the interview, the clinician proceeds in the usual manner by first asking the patient what brought him to the clinic and then elaborating the events, symp¬ toms, and issues of the present illness. It is neither neces¬ sary nor desirable to systematically ask questions about each successive hypothesis. Such a procedure would reduce the interview to a disjointed interrogation. The clinician, in gathering the relevant information, is as active and di¬ rective as necessary for diagnostic completeness. At the same time, he remains as nondirective as possible, so as to preserve the free flow of the patient's thoughts. Many of the hypotheses can be tested without the clini¬ cian's interfering at all with the flow of the interview. For instance, one can refute with relative certainty the idea that the patient is suffering from an organic illness with disturbed sensorium when the presentation is psychologi¬ cally understandable, when there are no schizophrenic-like or severe affective symptomatology, when the patient ap¬ pears physically well, and when there is no evidence of in¬ tellectual impairment, as inferred from the patient's pre¬ sentation of the history. All of these observations can be made with little or no verbal activity on the part of the clinician. Much of the evidence about personality style and ego assessment is derived in a similar fashion. Even when hypotheses require direct questioning for their confirma¬ tion, the questions can often become a part of the natural flow of the interview. I have found it very useful to review in my mind the complete list of hypotheses in two specific circumstances during the clinical examination. The first is when the hy¬ potheses that spontaneously arise during the first ten to 15 minutes of the interview fail to make clinical sense out of the data. The review becomes a source of new ideas, new approaches, and new meanings for previously dis¬ carded observations. The second circumstance in which I review all the hypotheses is five to ten minutes prior to completing each interview. This assures that all of the ma¬ jor diagnostic and therapeutic possibilities have been con¬ sidered. I have been surprised how often such an approach leads to the elicitation of data that substantially supple¬ ments the working case formulation. For example, during a 30-minute interview, I elicited data that led to the fol¬ lowing partial formulation: The patient, a 38-year-old Roman Catholic woman, reported mild depressive symp¬ tomatology beginning 12 months before when she di¬ vorced her alcoholic husband. She had considerable am¬ bivalence about the decision; she was now in a situation of relative social isolation, and she was feeling guilty about the possibility of renewed heterosexual contacts. These explanations for her clinical condition combining psycho-
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logic, social, and biologic hypotheses "felt right." Before completing the interview, I reviewed in my mind the en¬ tire list of hypotheses to ensure at least brief consid¬ eration of each. After pondering the unresolved grief hy¬ pothesis, I asked the patient whether or not anyone important to her had died. She immediately burst into
as she told me of her father-in-law's death six months before. This man, she explained, was a source of constant support to her. He shopped for her, listened to her troubles, and cared for her "more than my own hus¬ band." His relationship to her never faltered, even after the divorce. With his death there seemed to be no one to support her in her grief over this seemingly distant rela¬ tionship. The patient then recalled that she had been de¬ pressed for the six months since her father-in-law's death, not for the 12 months since the divorce. Without review¬ ing the hypotheses, this added partial formulation, given the pressure of time, might have been omitted.
tears
COMMENT
Psychiatry has set for itself the task of delivering care in clinical settings requiring rapid assessment and deci¬ sion making. Toward this end, enormous energy has been
expended to develop complex delivery systems employing a wide variety of mental health professionals. Despite this effort, the systems often deliver empty packages. In order to improve the quality of care, one of our tasks will be the reorganization of clinical knowledge acquired from in-depth work with patients and its reapplication and transmission to new clinical settings. The hypothesis generation and testing approach together with the devel¬ opment of a closed system of hypotheses is offered as one such way of reorganizing ideas. This approach is not in¬ tended to oversimplify the enormously complex clinical process. Rather, it analyzes and makes explicit this pro¬ cess so that learning may be facilitated.
In our own clinic, we have begun teaching "walk-in psy¬ chiatry" by this approach. In doing so, we have found that the language of hypothesis testing raises several impor¬ tant questions whose relevance is not limited to a par¬ ticular clinical setting: 1. For a particular setting, what is the best way to or¬ ganize data into hypotheses that are intellectually man¬ ageable and clinically useful? 2. What clinical observations should lead to the gener¬ ation of a given hypothesis? 3. Conversely, what hypotheses should be generated by a given observation? 4. What data are necessary to confirm or refute any
given hypothesis?
5. What methods or strategies may be employed to col¬ lect data necessary for the confirmation and refutation of
given hypothesis? These questions are seldom asked or answered in text¬ books of psychiatry. Clinicians, nevertheless, deal with them implicitly in deciding what to look for, how to look for it, and when to look for it. Such skills and processes are the heart of clinical practice. We learn them from teachers and from clinical experience, and we pass them on by the oral tradition. It is hoped that by making these processes explicit, much of what is now called clinical skill or intui¬ tion can more effectively be communicated by the written word. Our ability to learn from each other will then be en¬ hanced, and what we believe to be true can more easily be¬ come subject to validation. a
This investigation was supported in part by grant MH-22922-02, Na¬ tional Institute of Mental Health, Public Health Service. Arthur M. Kleinman, MD, Joel F. Rubinstein, MD, and the senior staff of the Department of Psychiatry, Massachusetts General Hospital, assisted in the preparation of this report.
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Arch Gen Psychiatry 17:385-406, 1967. 27. Simon RM: On eclecticism. Am J
Psychiatry 131:135-139, 1974. 28. Freedman DX, Gordon RP: Psychiatry under siege: Attacks from without. Psychiatr Ann 3:10-34, 1973. 29. Havens LL: Clinical methods in psychiatry. Inter J Psychiatry 10:7-28, 1972. 30. Havens LL: Approaches to the Mind. Boston, Little Brown & Co, 1973. 31. Shapiro D: Neurotic Styles. New York, Basic Books Inc, 1965. 32. Kahana RJ, Bibring GL: Personality types in medical management, in Zinberg N (ed): Psychiatry and Medical Practice in a General Hospital. New York, International Universities Press, 1964, pp 108-123. 33. Lazare A: The hysterical character in psychoanalytic theory: Evolution and confusion. Arch Gen Psychiatry 25:131-137, 1971. 34. Lazare A, Klerman GL, Armor D: Oral, obsessive and hysterical personality patterns: Replication of factor analysis in an independent sample. J Psychiatr Res 7:275-290, 1970. 35. Harris MR, Kalis BL, Freeman EH: Precipitating stress: An approach to brief therapy. Am J Psychother 17:465-471,1963. 36. Harris MR, Kalis BL, Prestwood AR, et al: Precipitating stress as a focus in psychotherapy. Arch Gen Psychiatry 5:219\x=req-\ 226, 1961.
37. Coleman JV: Aims and conduct of psychotherapy. Arch Gen Psychiatry 18:1-6, 1968. 38. Bibring E: The mechanism of depression, in Greenacre P (ed): Affective Disorders. New York, International Universities Press, 1953, pp 14-47. 39. Parkes CM: Bereavement: Studies of Grief in Adult Life. New York, International Universities Press, 1972. 40. Erikson EH: Childhood and Society. New York, WW Norton & Co Inc, 1950. 41. Schwartz LH, Schwartz JL: The Psychodynamics of Patient Care. Englewood Cliffs, NJ, Prentice-Hall Inc, 1972. 42. Bellak L, Hurvich M, Gediman HK: Ego Functions in Schizophrenics, Neurotics, and Normals. New York, John Wiley & Sons Inc, 1973. 43. Prelinger E, Zimet CN: An Ego-Psychological Approach to Character Assessment. London, The Free Press of Glencoe, Collier-Macmillan Ltd, 1964. 44. Vaillant GE: Theoretical hierarchy of adaptive ego mechanisms: A 30-year follow-up of 30 men selected for psychological health. Arch Gen Psychiatry 24:107-118, 1971. 45. Mechanic D: Social psychological factors affecting the presentation of bodily complaints. N Engl J Med 286:1132-1139,1972. 46. Wittkower ED, Dubreuil G: Psychocultural stress in relation to mental illness. Soc Sci Med 7:691-704, 1973. 47. Fox R: Illness, in Sills D (ed): International Encyclopedia of the Social Sciences, New York, Macmillan Co, 1968, vol 7, pp 90-96. 48. Zola I: Culture and symptoms. Am Soc Rev 31:615-630,1966.
L, Maretzki T (eds): Cultural Illness and Health: EsAdaptation. Washington, DC, American Anthropological Association, 1973. 49. Nader
says in Human
50. Tseng WH: The development of psychiatric concepts in traditional Chinese medicine. Arch Gen Psychiatry 29:569-575,1973. 51. Thomas CS, Bergen BJ: Social psychiatric view of psychological misfunction and role of psychiatry in social change. Arch Gen Psychiatry 12:539-544, 1965. 52. Rahe RH: Subjects' recent life changes and their near-future illness susceptibility, in Lipowski ZJ (ed): Advances in Psychosomatic Medicine. Basil, Switzerland, S Karger, 1972, vol 8, pp 2-19. 53. Coleman JV: Social factors influencing the development and containment of psychiatric symptoms, in Scheff TJ (ed): Mental Illness and Social Processes. New York, Harper & Row Publishers Inc, 1967, pp 158-168. 54. Coleman JV: Adaptive integration of psychiatric symptoms in ego regulation. Arch Gen Psychiatry 24:17-21, 1971. 55. Dunham HW: Resolving competing hypotheses, in Wechsler H, Solomon L, Kramer BM (eds): Social Psychology and Mental Health. New York, Holt Rinehart & Winston Inc, 1970, pp 191-202. 56. Shuval JT: Social Functions of Medical Practice: Doctor-Patient Relationships in Israel. San Francisco, Jossey-Bass, 1970. 57. Ruesch J: General theory of communication in psychiatry, in Arieti S (ed): American Handbook of Psychiatry. New York, Basic Books Inc, 1959, vol 1, chap 45. 58. Spiegel R: Specific problems of communication in psychiatric conditions, in Arieti S (ed): American Handbook of Psychiatry. New York, Basic Books Inc, 1959, vol 1, chap 46. 59. Ziegler FJ, Imboden JB: Contemporary conversion reactions. Arch Gen Psychiatry, 6:279-287, 1962. 60. Rabkin R: Conversion hysteria as social maladaptation. Psychiatry 27:349-363, 1964. 61. Berne E: Games People Play. New York, Grove Press, 1964. 62. Twaddle AC: The concepts of sick role and illness behavior, in Lipowski ZJ (ed): Advances in Psychosomatic Medicine. Basil, Switzerland, S Karger, 1972, vol 8, pp 162-179. 63. Winokur G, Clayton PJ, Reich T: Manic Depressive Illness. St. Louis, CV Mosby Co, 1969. 64. Feighner JP, Robins E, Guze SB, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63, 1972. 65. Woodruff RA, Goodwin DW, Guze SB: Psychiatric Diagnoses. New York, Oxford University Press, 1974. 66. Robins E, Guze SB: Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. Am J Psychia-
try 126:983-987, 1970.
67. Wender PH: The role of genetics in the etiology of schizophrenia. Am J Orthopsychiatry 39:447-458, 1969. 68. Kanfer FH, Saslow G: Behavioral analysis: An alternative to diagnostic classification. Arch Gen Psychiatry 12:529-538,1965. 69. Franks CM (ed): Behavior Therapy: Appraisal and Status.
New
York, McGraw-Hill Book Co Inc, 1969.
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and
Hypothesis Testing
Lazare, MD
\s=b\ Rapid assessment for decision making is a major goal of the initial psychiatric interview in walk-in clinics, emergency psy¬ chiatric services, and the ambulatory services of community mental health centers. To accomplish this task, the clinician must learn to elicit specific data to confirm or refute clinical hy¬ potheses rather than gather a complete history. This report, in formulating a hypothesis generating and testing approach for the initial psychiatric examination, proposes 16 hy¬ potheses that organize the clinical data necessary for most deci¬ sions. This approach is intended to help the clinician make ef¬ ficient use of limited time, guard him from coming to premature closure in the collection of data, and provide a stimulus for the exploration of relevant but neglected clinical questions. (Arch Gen Psychiatry 33:96-102, 1976)
are expected to make more rapid decisions in order to pro¬ vide competent care for more patients per unit time. What clinicians have done in developing their skills is to change strategies for diagnosis and case formulation from the collection and assimilation of large amounts of data to the generation and testing of various hypotheses. Using this new approach, they consider a limited number of pos¬ sibilities based on critical observations usually made early in the interview. They then proceed to elicit specific data to confirm or refute the hypotheses under consideration rather than "get a complete history." For the expert clini¬ cian, the probability that the correct diagnosis or formula¬ tion will be found among the early hypotheses is quite
high.13
learn the techniques of inter¬ and evaluation by collecting and recording numbers of observations from patients whom they see over extended periods of time. The data are then orga¬ nized in some fashion, such as chief complaint, present ill¬ ness, family history, developmental history, sexual his¬ tory, occupational history, medical history, and mental status examination. Finally, the clinician sorts out symp¬ toms, themes, and processes in order to establish a diag¬ nosis and formulation. The opportunity for this kind of intensive study is provided by inpatient units where pa¬ tients stay for a long enough period of time and by psy¬ chotherapy clinics where patients are stable enough to re¬ turn for several visits. As clinicians gain experience over months and years, they begin to take shortcuts. Sensing where the "pay dirt" is, they ignore extraneous information while focusing their energies on the elicitation of data that is apt to make a difference in clinical management. This improve¬ ment in efficiency becomes necessary because they soon
Cllargeiniviewing cians initially
Accepted for publication Feb 11, 1975. From the Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston. Reprint requests to the Department of Psychiatry, Massachusetts General Hospital, Fruit St, Boston, MA 02114 (Dr Lazare).
The hypothesis generation and testing approach, prac¬ ticed intuitively by most clinicians, has been alluded to but not systematically discussed in the literature on the general psychiatric examination.417 This process has been described in depth by Weisman18 and Erikson19 in their discussions of facts and inferences in the psychodynamic formulation. Elstein et al20 have shown that experienced internists examine medical patients by the generation and testing of hypotheses, thus confirming in a research setting what has long been noted in clinical medicine. A similar approach for the consultation in general practice has been recommended by the Royal College of General Practitioners.21 This group suggests that the hypotheses include not only diagnoses but an extended range of social and psychological components of the diagnostic process. In walk-in clinics, emergency psychiatric services, health maintenance organizations, and the ambulatory services of community mental health centers where a pri¬ mary goal is rapid assessment and decision making, it is obviously difficult to collect and assimilate large amounts of data. Yet clinicians must decide within a limited amount of time whether or not a patient is suicidal, is in need of hospitalization, needs psychotropic agents, can be helped in a few sessions, needs an extended diagnostic evaluation, or may leave with no additional care. The dan¬ ger is always present that incomplete data will result in incorrect decisions. This report will attempt to formulate an hypothesis
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for the initial psychiat¬ ric examination in walk-in clinics and related settings. Sixteen hypotheses that my colleagues and I have found useful in organizing clinical data will be described. I will attempt to show that this approach (1) helps the clinician make efficient use of limited time in attempting to be comprehensive, (2) guards the clinician from coming to premature closure in the collection of data, and (3) pro¬ vides a stimulus for the exploration of relevant but ne¬ glected clinical questions. In considering the interview as hypothesis generation and testing, the focus is on the collection and organization of data. Three important dimensions of the psychiatric ex¬ amination that will not be discussed are (1) the patient's goals and requests2224; (2) the therapeutic aspects of the clinician patient interaction, including the negotiation of goals and requests, which hopefully occur even before a specific treatment plan is formulated; and (3) the tech¬ niques necessary to elicit relevant data.
generating and testing approach
A MULTIDIMENSIONAL APPROACH
The hypotheses to be considered and the clinical meth¬ ods needed to test them depend on a theoretical frame¬ work. I shall, therefore, make explicit an approach that we have found useful. This approach and its clinical implica¬ tions are discussed more fully elsewhere.25 Although "human beings are simultaneously biological organisms, psychological selves, behaving animals, and members of social systems,"25 we lack a theory of human behavior that satisfactorily integrates these four dimen¬ sions. Attempts by psychoanalysts, behaviorists, or gen¬ eral system theorists to describe a comprehensive theory of human behavior are either too cumbersome or not ade¬ quately inclusive. Clinicians, in the absence of such a com¬ prehensive theory, implicitly use one or a combination of models that include the psychologic, social, biologic, and behavioral. These models may be thought of as different lenses through which one can observe a single object. Each lens has its own value and each has its own limitations. The choice of conceptual approach in clinical practice has serious implications, since it may determine the method by which one collects data, the data that are con¬ sidered relevant, and the treatment that is most appropri¬ ate. For example, a clinician using a psychologic approach to examine a depressed patient may elicit a history of un¬ resolved grief or explore the psychologic meaning of the precipitating event in order to understand the issues that have led to the depression. A clinician using a social ap¬ proach to examine the same patient may determine how the disruption of the social matrix led to the patient's be¬ coming depressed. Hopefully, there will be some way of reestablishing some social equilibrium. Using a biologic approach, the clinician will inquire into the signs and symptoms of a unipolar or bipolar depression, previous episodes of depression, and family history of depressive illness in the hopes of diagnosing a syndrome for which there is a somatic treatment. Using a behavioral ap¬ proach, the clinician will elicit the undesired behaviors to¬ gether with their antecedent and reinforcing conditions in the hopes of positively reinforcing normal behavior or ex¬ tinguishing depressive behavior.
In clinical practice, the use of one or a combination of the four conceptual models is implicitly determined by many variables. These include the ideology of the thera¬ pist, the diagnosis, the responsiveness of the symptoms to somatic treatment, the treatment resources, the social class of the patient, and other personal attributes such as verbal intelligence, psychological mindedness, young adult age, psychological strengths, likeability, and attractive¬ ness.26
Clinicians are sometimes unaware of how these vari¬ ables influence their clinical judgment. When this hap¬ pens, they run the risk of dealing with diffuse and incom¬ plete data, an approach that may be inappropriately termed "eclectic."27 In the examination of the walk-in patient for whom various conceptual frameworks are often relevant, the pit¬ falls described above can be minimized by simultaneously formulating the problem from psychologic, social, biologic, and behavioral perspectives. This means that hypotheses from all four theoretical frameworks are considered. In this way, the chances of making the appropriate clinical mix yielding the optimal therapeutic gain will be en¬ hanced.25·2830 HYPOTHESES: HYPOTHESIZED PARTIAL FORMULATIONS
A clinician brings to the interview partial formulations based on his previous experience. A formulation is defined here as a concept that organizes, explains, or makes clini¬ cal sense out of large amounts of data and influences the treatment decision. These concepts include clinical syn¬ dromes such as schizophrenia; personality styles, such as the hysterical personality; social conditions, such as social isolation; and even symptoms such as suicidal behavior. These concepts may be "apples and oranges," but they do represent clusters of information that clinicians find use¬ ful in understanding patients. In Weisman's terms, "This is the nature of communication between people—to oper¬ ate on many levels at once with different words, different objects, and different meanings."18 These concepts are partial formulations because any one alone is insufficient to provide adequate understanding of any given patient. In the process of bringing these partial formulations to the interview for consideration, they become hypotheses to be tested. The clinician by thinking in terms of hypotheses keeps himself from being bombarded or overloaded with large amounts of unstructured data. Each new observation can now be considered in terms of its relevance to a limited number of hypotheses under consideration instead of being one out of thousands of possible facts.20 Two problems immediately arise in applying this ap¬ proach to the psychiatric examination. The first is that in considering a few hypotheses usually generated early in the interview, the clinician may come to premature clo¬ sure, thereby ignoring more relevant hypotheses. The sec¬ ond is that, given the rich and varied data of clinical psy¬ chiatry, there must be thousands of possible hypotheses or ways of organizing data. A solution to both problems would be the development of a manageable list of hypoth¬ esized partial formulations based on current psychiatric knowledge, which would organize most of the observations
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might relate to decision making. The entire range of hypotheses could then be considered, at least briefly, dur¬ ing each interview. The composition of such a list might vary with the clinical setting and would undoubtedly change with advances in the field. This report will propose 16 hypotheses that my col¬ leagues and I have found useful in evaluating and treat¬ ing patients in our walk-in clinic. They are organized un¬ der four major headings: psychologic, social, biologic, and behavioral (according to the conceptual approach whose theory and methods generate, confirm, or refute the hy¬ pothesis). These hypothesized partial formulations are in¬ tended to become neither decision trees nor a complete list of diagnoses. Rather, they are intended to assist in the clinical understanding of patients so that decisions can more effectively be made, and to provide a basis for impor¬ tant theoretical discussions as to which hypotheses belong that
in such a list. There is some overlap between various partial formula¬ tions since they may explain similar observations from different perspectives. For instance, calling a patient schiz¬ oid (psychologic) or socially isolated (social) may be de¬ scribing some of the same phenomena from different per¬
spectives.
For any given patient, several partial formulations will be necessary to approach "complete understanding"; for example, knowing that a patient is suffering from unre¬ solved grief tells us a great deal. Add to this partial for¬ mulation the knowledge of an obsessional personality style, the ego's incapacity to bear painful affective states, relative social isolation, and a behavioral system that pun¬ ishes grieving behavior. These additional partial formula¬ tions provide the clinician with considerably more power to understand and treat the patient.
Psychologic Hypotheses Knowledge of the patient's personality style explains in part why he has come for treatment. Knowledge of the personality style may be important in understanding the patient's psychological vulnerabilities and, therefore, the meaning of the stress or precipitating event. It may also predict the defensive posture that the patient will employ to keep the clinician from getting to the important psy¬ chological issues surrounding the current problem.3134 Armed with this knowledge, the clinician can avoid the patient's diversionary tactics and more effectively get to the heart of the matter. This hypothesis, with its potential for making sense out of large amounts of data, can often be inferred from a relatively small number of observa¬ tions obtained early in the interview. Knowledge of the precipitating event and its dynamic meaning explains in part why the patient has come for treatment. It is essential to learn the stress or precipi¬ tating event (when present) that precedes the onset of
symptoms. At least
important
is the
psychological meaning of this event. Does the event mean to the patient that he is now hopeless, weak, powerless, out-of-control, as
failure, unreal, or unloved? Does attacked, penetrated, vio¬ lated, damaged, overwhelmed, smothered, ridiculed, or destructive, bad, it
mean
a
to him that he is
cheated?3538 Is the precipitating event evidence of a recur-
rent neurotic theme? Knowing the psychological meaning of the event improves rapport because the patient now be¬
lieves the clinician really appreciates what is happening. At least as important, the clinician may know with consid¬ erable specificity the psychological work that needs to be done. The patient's problem can be understood in part as a manifestation of unresolved grief. This hypothesis is a variation on the previous one when it is determined, for instance, that the symptoms followed a loss that the pa¬ tient inadequately mourned. The grief hypothesis, how¬ ever, is worth considering separately for several reasons: (1) the symptom picture may not follow a discrete stress but may occur after an anniversary of a loss, a holiday, or a minor event symbolizing the loss; (2) the symptom pic¬ ture of unresolved grief represents a relatively clear-cut clinical syndrome39; (3) specific methods must be employed to elicit the necessary observations to confirm or refute the hypothesis; and (4) I have found a relatively high inci¬ dence (10% to 15%) of patients coming to a walk-in clinic for whom unresolved grief is an important issue. The patient's problem can be understood in part as a de¬ velopmental crisis. When it is difficult to understand the patient's presentation as a reaction to a discrete event or as a manifestation of unresolved grief, the problem may be better understood as part of a developmental crisis. Using this approach, the clinician considers what series of issues the patient at his stage of development is apt to be suffering from. For instance, a 50-year-old woman may well be struggling simultaneously with menopause, chil¬ dren leaving home, strains in the marital relationship, and the death of a parent. With the developmental crisis hy¬ pothesis in mind, the clinician can elicit specific historical data that may clarify the clinical problem.40"41 The patient's problem can be understood in part in terms of ego functioning and related psychodynamic is¬ sues. There are many subconcepts or ways of organizing the data of ego assessment and related psychodynamic is¬ sues. These include recurrent neurotic themes, meaning of neurotic symptoms, predominant defense mechanisms, overall defensive success, reality testing, sense of reality, judgment, thought processes, tolerance to stress, capacity to bear affects, impulse control, patterns of regression, au¬ tonomous functioning, synthetic functioning, conflict-free areas, libidinal fixation, object relations, sexual identi¬ fication, superego severity and integration, and psycho¬ logical mindedness. A clinician using a psychodynamic ap¬ proach usually chooses a few of these overlapping concepts to help explain the patient's problem and plan treatment. Confirmation of the ego-assessment hypothesis often re¬ quires data from many sources including developmental history, dreams, associations, and transference reac¬ tions.4244 Social
Hypotheses Cultural factors explain in part the patient's problem and his reasons for seeking treatment. It is important to consider to what degree cultural factors influence percep¬ tions, beliefs, values, behavioral norms, and expectations that give clues as to the choice, expression, and serious¬ ness
of
symptomatology. Cultural
factors also influence
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the choice of and attitudes toward treatment and even the basic communicative processes between clinician and pa¬ tient.4550 The patient's problem can be understood in part in terms of a change in the social space. The social space (so¬ cial network) consists of all relevant people (and animals) in the patient's life—at home, with friends, at school, and on the job. The clinical presentation can often be under¬ stood in terms of a disruption or impending disruption of the social space that had previously supported the patient. To explore this hypothesis, the patient may be asked to list and briefly describe all the important people in his life. By listening for the order in which people are listed, for the associated affective responses, and for the omissions of important people, the clinical picture often falls into place. The recovery process will depend in large part on the availability of important relationships.5154 Social isolation explains in part the patient's problem. For many patients who come to a walk-in clinic, the pau¬ city of their social contacts may explain what they ask for and what they need from the clinician.55 They often make modest requests, perhaps a prescription refill or someone to speak with for a few minutes. The social isolation may be characterological in origin, or it may be the result of so¬ cial transition such as a recent move. Shuvall has shown that social transition is a cause for presentation to medi¬ cal clinics in Israel.56 This hypothesis is tested only by spe¬ cific inquiry into the patient's social space. The patient's problem can be understood in part as a so¬ cial communication. The symptom or even the clinic visit can be understood as an attempt to influence or to commu¬ nicate something to some person, social group, or institu¬ tion. This hypothesis, like the one above, can be deter¬ mined by reviewing the persons or groups in the patient's life space. The questions are as follows: Who wants what from whom? and Who is doing what to whom? Sometimes the communication can be discerned by watching the pa¬ tient with a relative in the waiting room or at a family conference. The communication may or may not be con¬ scious.5762 The patient's problem can be understood in part in terms of its social impact, including suicide or violence. The importance of this hypothesis is self-evident. Once it is confirmed that the patient is suicidal, violent, or in dan¬ ger of harming others, the clinician then calls forth a new body of knowledge to explore seriousness, cause, and
treatability.
Biologic Hypotheses The
patient's problem can be understood in part as an affective disorder (unipolar or bipolar).6365 This hypothesis should be considered because of its rela¬ tively high incidence, its treatability, the dangers inher¬ ent in the clinical course when rigorous treatment is de¬ layed, and the important differential diagnosis of syndromes that appear to be affective disorders. Although psychologic, social, and behavioral considerations are es¬ sential in the understanding and management of these patients, affective disorder is listed as biologic since the hypothesis is usually established by the method of the biologic approach—observations of signs and symptoms
through time.
In
addition, there
are
treatments for these disorders.
important somatic
The patient is suffering in part from schizophrenia."46'' This hypothesis, like the previous one, should be consid¬ ered because of its frequency, its treatability, the dangers inherent in its clinical course when treatment is delayed, and the differential diagnoses of syndromes that assume this manner. Although the hypothesis is usually estab¬ lished by the biologic method, psychodynamic, social, and behavioral considerations are essential in the under¬ standing and management of these patients. The patient's problem can be understood in part as an organic disease. It is useful to divide this hypothesis into conditions that are with and without impairments of the sensorium. The latter group is most likely to be over¬ looked. The clinician should consider a differential diag¬ nosis that includes organic illness even in the presence of a clean sensorium when he observes psychotic thinking, mania, depression, anxiety, impotence, eneuresis, syncope, amnesia, pain, and various sensory and motor distur¬ bances. The patient is suffering in part from alcohol or drug abuse. This hypothesis deserves separate consideration since (1) its occurrence is common; (2) patients are reluctant to acknowledge their abuse of alcohol and drugs; (3) health professionals because of hostile feelings toward many of these patients may overlook the problem; and (4) the ab¬ use of these agents, aside from their complex causes, sets in motion a series of medical, social, and psychological problems that may require special therapeutic techniques. The patient's problem can be understood in part in terms of symptoms responsive to psychotropic agents. The separate consideration of psychotropic agents assures that an important treatment possibility is not overlooked. Behavioral
Hypotheses
The patient's problem can be understood in part in be¬ havioral terms. For each patient, the clinician should con¬ sider whether or not an understanding of the undesired behaviors together with their antecedent and reinforcing events will lead to a plan of treatment. In addition, it should be considered whether or not there already exists specific treatment programs for these behaviors.68·69 THE DYNAMICS OF HYPOTHESIS GENERATION AND TESTING
Hypothesis generation and testing can be thought of as three-step mental process repeated many times through¬ out the interview by which the clinician (1) collects data (makes observations); (2) generates, confirms, and refutes hypotheses on the basis of the data collected; and (3) em¬ ploys clinical methods or strategies to elicit additional data that will generate new hypotheses and confirm or re¬ a
fute old
ones.
Data Collection
The observations
data that lead to hypothesis gener¬ and refutation may come (1) from ation, confirmation, outside the patient (previous records, clinic face sheet, and information from the family); (2) from the patient's bio¬ graphical reconstructions; (3) from the mental status exor
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amination (behavior observations made during the inter¬ view); (4) from the physical examination and laboratory data; (5) from psychodynamic material including dreams, fantasies, memories, associations, recurrent themes, transference, and countertransference reactions; and (6)
from social interactions in ences,
homes,
or
waiting neighborhoods.
rooms,
family confer¬
What there is to observe is a result of the clinician's methods, the patient's disorder, and other dimensions of the clinical situation such as the size of the room, the posi¬ tion of the chairs, the duration of the wait, and the time of day. The clinician's ability to perceive the observations de¬ pends on what he thinks is important and on his ability to see what is in front of him.
Hypothesis Generation and Testing
Although the clinician can briefly consider all of the hy¬ potheses on the list, it is usually possible to explore only a few in depth. The selection of these few is best deter¬ mined by several criteria. 1. One considers hypotheses that are most probable on the basis of available data. For example, fastidious dress may lead to consideration of an obsessional style; recur¬ rent presentations on the same date may lead to consid¬ eration of unresolved grief. 2. One considers those hypotheses that are most serious, even though they may not be highly probable. These in¬ clude suicide, organic brain disease, and schizophrenia. 3. One gives special consideration to those hypotheses that have a high probability of being reversed with treat¬ ment, such as primary affective disorders, unresolved grief, and acute brain syndromes. 4. One considers those hypotheses for which there are treatment resources. For example, if psychotherapy time is available, one explores various ego functions to deter¬ mine whether or not the patient is a candidate for this treatment.
5. One considers those hypotheses that the patient be¬ lieves are relevant. The patient is often right and, if he is wrong, it will be important that he knew his concerns have been taken seriously. Which hypotheses the clinician tests depend not only on the priorities listed above but on his awareness of the range of hypotheses to be tested and on his ability to re¬ late specific data to the formation, refutation, and confir¬ mation of hypotheses. For instance, the clinician must know that delusions may be part of schizophrenia, affec¬ tive disorders, or organic brain disease, if this symptom is to alert him to test these hypotheses.
Strategies: Methods After the clinician generates several hypotheses on the basis of the available observations, he develops a strategy to test these hypotheses. To do this, the clinician must know what additional data are required to confirm or re¬ fute any given hypothesis. He then sets out to collect these data by various methods, such as direct questioning, sitting in silence, employing the associative anamnestic technique, encouraging free associations, speaking to the family, testing the patient's memory, paying attention to his own subjective responses, stressing the patient, using
sodium amytal, or evaluating the response of a trial medi¬ cation. Many of these methods can be traced to the four basic conceptual frameworks previously described. The ef¬ fectiveness of the method will depend on choosing the proper one for the particular hypothesis, the skill of the clinician, and the responsiveness of the patient. Particular methods may have to be withheld if they are antitherapeutic. For example, the stress of extended silence may yield useful data but impair the treatment relationship. Conduct of the Interview
In conducting the interview, the clinician proceeds in the usual manner by first asking the patient what brought him to the clinic and then elaborating the events, symp¬ toms, and issues of the present illness. It is neither neces¬ sary nor desirable to systematically ask questions about each successive hypothesis. Such a procedure would reduce the interview to a disjointed interrogation. The clinician, in gathering the relevant information, is as active and di¬ rective as necessary for diagnostic completeness. At the same time, he remains as nondirective as possible, so as to preserve the free flow of the patient's thoughts. Many of the hypotheses can be tested without the clini¬ cian's interfering at all with the flow of the interview. For instance, one can refute with relative certainty the idea that the patient is suffering from an organic illness with disturbed sensorium when the presentation is psychologi¬ cally understandable, when there are no schizophrenic-like or severe affective symptomatology, when the patient ap¬ pears physically well, and when there is no evidence of in¬ tellectual impairment, as inferred from the patient's pre¬ sentation of the history. All of these observations can be made with little or no verbal activity on the part of the clinician. Much of the evidence about personality style and ego assessment is derived in a similar fashion. Even when hypotheses require direct questioning for their confirma¬ tion, the questions can often become a part of the natural flow of the interview. I have found it very useful to review in my mind the complete list of hypotheses in two specific circumstances during the clinical examination. The first is when the hy¬ potheses that spontaneously arise during the first ten to 15 minutes of the interview fail to make clinical sense out of the data. The review becomes a source of new ideas, new approaches, and new meanings for previously dis¬ carded observations. The second circumstance in which I review all the hypotheses is five to ten minutes prior to completing each interview. This assures that all of the ma¬ jor diagnostic and therapeutic possibilities have been con¬ sidered. I have been surprised how often such an approach leads to the elicitation of data that substantially supple¬ ments the working case formulation. For example, during a 30-minute interview, I elicited data that led to the fol¬ lowing partial formulation: The patient, a 38-year-old Roman Catholic woman, reported mild depressive symp¬ tomatology beginning 12 months before when she di¬ vorced her alcoholic husband. She had considerable am¬ bivalence about the decision; she was now in a situation of relative social isolation, and she was feeling guilty about the possibility of renewed heterosexual contacts. These explanations for her clinical condition combining psycho-
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logic, social, and biologic hypotheses "felt right." Before completing the interview, I reviewed in my mind the en¬ tire list of hypotheses to ensure at least brief consid¬ eration of each. After pondering the unresolved grief hy¬ pothesis, I asked the patient whether or not anyone important to her had died. She immediately burst into
as she told me of her father-in-law's death six months before. This man, she explained, was a source of constant support to her. He shopped for her, listened to her troubles, and cared for her "more than my own hus¬ band." His relationship to her never faltered, even after the divorce. With his death there seemed to be no one to support her in her grief over this seemingly distant rela¬ tionship. The patient then recalled that she had been de¬ pressed for the six months since her father-in-law's death, not for the 12 months since the divorce. Without review¬ ing the hypotheses, this added partial formulation, given the pressure of time, might have been omitted.
tears
COMMENT
Psychiatry has set for itself the task of delivering care in clinical settings requiring rapid assessment and deci¬ sion making. Toward this end, enormous energy has been
expended to develop complex delivery systems employing a wide variety of mental health professionals. Despite this effort, the systems often deliver empty packages. In order to improve the quality of care, one of our tasks will be the reorganization of clinical knowledge acquired from in-depth work with patients and its reapplication and transmission to new clinical settings. The hypothesis generation and testing approach together with the devel¬ opment of a closed system of hypotheses is offered as one such way of reorganizing ideas. This approach is not in¬ tended to oversimplify the enormously complex clinical process. Rather, it analyzes and makes explicit this pro¬ cess so that learning may be facilitated.
In our own clinic, we have begun teaching "walk-in psy¬ chiatry" by this approach. In doing so, we have found that the language of hypothesis testing raises several impor¬ tant questions whose relevance is not limited to a par¬ ticular clinical setting: 1. For a particular setting, what is the best way to or¬ ganize data into hypotheses that are intellectually man¬ ageable and clinically useful? 2. What clinical observations should lead to the gener¬ ation of a given hypothesis? 3. Conversely, what hypotheses should be generated by a given observation? 4. What data are necessary to confirm or refute any
given hypothesis?
5. What methods or strategies may be employed to col¬ lect data necessary for the confirmation and refutation of
given hypothesis? These questions are seldom asked or answered in text¬ books of psychiatry. Clinicians, nevertheless, deal with them implicitly in deciding what to look for, how to look for it, and when to look for it. Such skills and processes are the heart of clinical practice. We learn them from teachers and from clinical experience, and we pass them on by the oral tradition. It is hoped that by making these processes explicit, much of what is now called clinical skill or intui¬ tion can more effectively be communicated by the written word. Our ability to learn from each other will then be en¬ hanced, and what we believe to be true can more easily be¬ come subject to validation. a
This investigation was supported in part by grant MH-22922-02, Na¬ tional Institute of Mental Health, Public Health Service. Arthur M. Kleinman, MD, Joel F. Rubinstein, MD, and the senior staff of the Department of Psychiatry, Massachusetts General Hospital, assisted in the preparation of this report.
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